Insurance coverage for pharmacogenomic testing in the USA

Coverage of pharmacogenetic tests by private health insurance companies

OBJECTIVE

To assess the coverage of clinically relevant pharmacogenetic tests by the top 41 private insurance companies in the United States.

DESIGN

Websites of insurance companies were searched for medical policies addressing 34 common and clinically relevant pharmacogenetic tests referenced by the Clinical Pharmacogenetics Implementation Consortium, PharmGKB, and Food and Drug Administration product labeling. Those policies were subsequently reviewed for the coverage of the tests by gene-drug pair and by company. Policies were subsequently reviewed to determine coverage of pharmacogenetic tests by gene-drug indication group (GDIG) and an insurance company.

SETTINGS AND PARTICIPANTS

Not applicable.

OUTCOME MEASURES

Within unique policy sets, the following were analyzed: (1) the number of times each GDIG was mentioned; (2) the percentage of times each GDIG was mentioned; (3) when mentioned, the number of times each GDIG was covered; (4) when mentioned, the percentage of times each GDIG was covered; and (5) regardless of being mentioned, the percentage of times each GDIG was covered.

RESULTS

A total of 223 medical policies mentioning pharmacogenetic tests were retrieved, representing 34 unique policy sets from 41 companies. Thirty-three companies had their policies accessible on their website. Approximately 50% of GDIGs were unanimously mentioned in all policies but were covered only < 20% of the time. When mentioned in a policy, 7 GDIGs were uniformly covered, and 11 GDIGs were uniformly not covered. Overall, insurance companies covered approximately 40% of GDIGs mentioned in their policies.

CONCLUSION

The medical policies addressing recommended pharmacogenetic tests were not readily accessible on websites of the top private health insurance companies. The coverage and payments of the tests varied by the company and gene-drug pairs and remain suboptimal.

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